When an accident happens whether it has resulted in an injury or not, the cause(s) of that accident needs to be determined and this can only be through accident investigation. The primary aim of accident investigation is not to apportion blame or find out whose fault it is but rather to find facts and the root cause of the accident, so that it can be prevented from happening again. You also need to investigate accidents to meet and comply with legal requirements and deal with any compensation claims. Most importantly, accidents should be investigated to help prevent reoccurence.
To investigate accidents, you need to ensure that the investigator is experienced in accident causation and has knowledge of the company’s work processes, policies and procedures. Better still, you could have someone who knows a lot about the work and people involved support the investigator with their investigation. The time between the accident and investigation should be very short to prevent loss of information (witnesses might no longer be available)or tampering with the accident scene.
Here are six steps inspired by CSI to ensure you conduct a thorough investigation:
Step 1. Secure the accident scene. This is to ensure material evidence is not moved. Think CSI. Ever seen an episode of CSI? No one comes in except the forensic guys. No one touches anything. No one takes out anything or changes the position of things. Everything is left as it was met. That’s exactly what you should do. You should ensure nothing is removed or brought in except of course a camera and all materials needed.
Step 2. Gather data and information. This can be done using observation, interviews and photos. You need to speak to witnesses and employees. Record your interviews. Write down your observations. Take pictures and if possible make sketches. You should avoid intimidating or prompting witnesses. Keep an open mind and don’t jump into conclusions while the investigation is still going on. Ask open questions. For example, What were you doing at the time of the accident? Or what was the weather like at time of the accident? Don’t ask “where you here at the time of the accident or was it raining at time of accident?” Asking open questions allows the witness to give detailed unbiased information rather than just saying yes or no.
Step 3. Re-enact the accident. Re-enact or replay the accident to determine the sequence of events before, during and immediately after the accident. It could be that there is a problem with the process and not the individual involved so take care while re-enacting to prevent another accident from happening. While re-enacting, analyze each event for surface and root causes that contributed to the event. Surface causes are hazardous conditions and unsafe acts that directly caused or contributed to the accident; while root causes refers to underlying safety management system weaknesses and inadequacies. This infomation will come in handy soon ( see step 4).
Step 4. Look into Background information. As I said in step 3, there could be a problem with the work processes. So you need to look at the company’s safety management system by looking at things like health and safety policy, company policies, training records, safety committee meeting minutes, inspection and audit reports, accident reports, maintenance schedules and reports and safe systems of work. This can help identify causes that are not physical or due to unsafe behaviour.
Step 5. Develop recommendations for immediate and long-term corrective actions. Consider carefully what recommendation you will be making. Don’t just make them because you feel you have to. Your recommendations have to relevant and designed to prevent occurrence of similar accident. Recommendations must provide immediate and long-term corrective and preventive actions. Recommendations should not look at assigning fault or disciplining the person or persons who may be at fault.
Step 6. Write the accident report. You need to write down a step by step account of your findings listing all possible causes. Your findings must be supported by evidence be it assumptious, physical or based on witnesses account. If possible, avoid using a standard form to write the final report. This is important so that you are not limited in how and what information you present so that the written report will be presented in a clear and unbiased manner. If your organisation has a standard form, then use this form but don’t limit yourself. You can add your photographs, draft report and your observations as an attachment to this form. Your report must be easy for all to understand – avoid the use of jargons.
It helps to know how and why accidents happen. Read this post for some tips.